Dear editor
We read thoroughly the article by Liao et alCitation1 “Decreased hospital charges and postoperative pain in septoplasty by application of enhanced recovery after surgery” and we found it very interesting and innovative, given the low level of evidence about the application of the enhanced recovery after surgery (ERAS) protocol in otolaryngologic field. Nevertheless, there are some points that we have focused on since they remain unclear and decrease the scientific reliability of the results. First, we have noticed that the primary endpoint is not well defined, and this is reflected in the whole setting of the study: randomization method, allocation of the patients, statistical analysis, and results. Whilst perioperative management of the ERAS group is quite well described, however, the “common processing” of the control group remains undefined. In our opinion, for all these reasons, readers cannot fully understand the author’s objective, thus making this study difficult to reproduce.
Moreover patients in the ERAS group were managed with local anesthesia and postoperative administration of oral nonsteroidal anti-inflammatories (NSAIDs), differently from the control group, which only received general anesthesia and no postoperative analgesia. This affects evaluation of real benefits of the innovative surgical approach, consisting of the avoidance of postoperative nasal filling and the use of a new nasal septum suture.
According to the study results, in the ERAS group there was a decrease in the hospital stay of 1.4 days (4.4 vs 5.8) compared with that in the control group. This positive result could be improved if we consider that other authors shortened more endoscopic septoplasty length of stay, having fewer long-stay patients (>48 hours).Citation2 In the present literature there are no adequate neither standardized studies about septoplasty costs analysis; indeed the author’s aim to evaluate hospital charges is desirable. From this perspective, the choice of sedation anesthesia instead of general anesthesia in the ERAS group could be a suitable manner to reduce healthcare costs, total operation time, and postoperative complications.Citation3
Disclosure
The authors report no conflicts of interest in this communication.
Dear editor
Thank you for your comments and suggestions on this article.
Regarding the first point, the primary endpoint of this study was the length of hospital stay and postoperative pain. In addition, secondary endpoints such as nasal congestion, sleep disorder, anxiety and other conditions were also observed to improve in the study. With regards to “common processing” of the control group, it refers to the standard procedure of each region which varies and therefore it was difficult to describe in detail. A common denominator of the “common processing” is that the current hospital standard in the region for treating septoplasty was performed, without considering ERAS implementation. Therefore, the design suits the objective of the study in comparing treatment procedure with and without ERAS implementation.
In this study, the main evaluation is the application of ERAS as a means of avoiding the postoperative nasal filling that were found as a major contributor to post-operative discomfort. Therefore, the study did not account for comparison of the individual procedure. However, the point raised is an interesting one and we may look into individually evaluating the surgical procedure alone in the future with more comparable anesthetic procedure.
Thank you for the suggestion in further improving the hospitalization time. The modest decrease of hospitalization time in ERAS group by 1.4 days (4.4 vs 5.8) (<48 h) shows that our ERAS implementation is still in the preliminary stage and can still be further improved. The suggestions will surely contribute to the further refinement of the ERAS procedure in the otolaryngologic field.
Overall, we concur with the letter that the implementation of ERAS requires further refinement. The purpose of our study is to show the feasibility of ERAS implementation in the Otolaryngologic field and its potential benefits towards hospital charges and patient quality of life. We hope that we have sufficiently addressed the points in the letter and we welcome any future correspondence.
Disclosure
The authors report no conflicts of interest in this communication.